Form I-510 Guarantee of Payment

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection

OMB No. 1651-0127
Expires 02/28/2013

GUARANTEE OF PAYMENT
Port of Entry
File No.
Pursuant to the provisions of section 253 of the Immigration and Nationality Act,
I,

Name (First)

as

(Initial)

(Last)

(Owner, agent, consignee, commanding officer, or master)

of the vessel or aircraft

(Name of vessel or aircraft)

employing the alien crewman
who upon the arrival at the port of
on

(Name of port)

was found to be afflicted with, or suspected of being afflicted with

(Date of arrival)
(Name of affliction)

,

hereby guarantee to pay any and all expenses incurred or to be incurred for the hospitalization, care, and treatment, and
for burial in the event of death, of the said alien crewman.
Dated at

this

day of

(month/year)

(Signature of Guarantor)

Approved this

day of

(month/year)
(Signature of Officer)

(Title of Officer)

Paperwork Reduction Act Statement: An agency may not conduct or sponsor an information collection and a person is not required to
respond to this information unless it displays a current valid OMB control number and an expiration date. The control number for this
collection is 1651-0127. The estimated average time to complete this application is 5 minutes. If you have any comments regarding the
burden estimate you can write to U.S. Customs and Border Protection, Office of Regulations and Rulings, 799 9th Street, NW.,
Washington DC 20229.

CBP Form I-510 (12/09)